Failure to Provide Immediate and Effective CPR to Full Code Resident
Penalty
Summary
The facility failed to provide immediate, effective, and uninterrupted basic life support (BLS) and cardiopulmonary resuscitation (CPR) to a resident who was identified as full code and found unresponsive and not breathing. Despite the resident's Physician Orders for Life Sustaining Treatment (POLST) indicating full code status, staff did not promptly activate the emergency response system (code blue), initiate the BLS sequence, or call 911 emergency services in a timely manner. There was a delay of 26 to 31 minutes from the time the resident was reported unresponsive to the time 911 was called. During this period, staff did not follow the facility's policy and procedure for CPR, which required immediate action. The staff involved, including an RN and two LVNs, did not perform effective and continuous CPR as required by professional standards and the facility's policy. Instead of performing chest compressions and rescue breaths at the recommended ratio and rate, the RN described performing a chest rub or gentle circular motion on the resident's chest, which does not meet the criteria for effective CPR. There was also no evidence that rescue breaths were provided, and the use of the crash cart and other emergency equipment was inconsistent. Interviews revealed confusion among staff regarding the resident's code status, the sequence of emergency actions, and the proper technique for CPR. The resident had a complex medical history, including pneumonia, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease (COPD) with exacerbation. The care plans and physician orders indicated the need for close monitoring and immediate intervention in the event of respiratory or cardiac arrest. Despite these directives, staff failed to document abnormal vital signs, did not communicate changes in the resident's condition effectively, and did not adhere to the established emergency protocols. When emergency medical services arrived, the resident was found deceased, with signs of lividity and no signs of life, indicating a significant lapse in the provision of life-sustaining treatment.